Provider Demographics
NPI:1558076513
Name:SPECTRUM CONNECTION BEHAVIORAL HEALTH LLC
Entity Type:Organization
Organization Name:SPECTRUM CONNECTION BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:RUGULEISKI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-261-2740
Mailing Address - Street 1:1315 HIGHWAY 2 STE 4
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-2724
Mailing Address - Country:US
Mailing Address - Phone:208-261-2740
Mailing Address - Fax:208-625-2062
Practice Address - Street 1:1315 HIGHWAY 2 STE 4
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-2724
Practice Address - Country:US
Practice Address - Phone:208-261-2740
Practice Address - Fax:208-625-2062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-13
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806106400Medicaid